Urinary infection (adult)
What should I do if I think I have a urinary infection?
If you have pain in the bladder area (pictured below), pain when passing urine, a need to urinate frequently or urine that is dark or strong-smelling, especially if you have a fever of 38ºC or more, you should contact your GP for further advice.
These symptoms are all non-specific. They can be caused by many other conditions such as sexually-transmitted infection, vaginal thrush (in women), chemical irritants (soap & deodorants), stones (in the kidney, ureter or bladder), interstitial cystitis, bladder cancer or inflammation in the prostate gland (prostatitis).
It is, therefore, important that you see your GP to arrange appropriate investigations to establish the exact cause of your symptoms. Failure to treat a bladder infection promptly can cause infection to spread to the kidneys. In severe cases, this may result in blood poisoning (septicaemia).
What are the facts about urinary infection?
- Most urine infections are caused by bacteria (such as E coli, pictured above the right-hand links column) which come from your bowel
- In women, the urethra (water pipe) is very close to the anus making it easy for bacteria to reach the bladder and cause infection
- Most women have at least one attack of urinary infection during their lifetime and 20% of women suffer repeated attacks. This is more likely in women who are pregnant, sexually-active or postmenopausal
- Cystitis in men and children is more serious because it is often caused by underlying problems such as an enlarged prostate, prostatitis or inherited abnormalities
- Mild urinary infections usually clear within a few days and may not always require treatment with antibiotics
- Untreated, more severe infections can involve the kidneys and may even spread into the bloodstream
- Recurrent urinary infections in women can often be managed by simple, “self-help” measures
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for suspected urinary infection. This will normally include one or all of the following:
1. A full history
Your GP will take a full urological history with special attention to previous urinary infections, periods of dehydration, your sexual activity, any intake of acidic or spicy foods and any relevant past medical problems.
2. A physical examination
A general physical examination, including rectal examination (in men) and vaginal examination (in women) will normally be performed. Your blood pressure will be measured as part of this assessment.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is usual to measure kidney function and to check the blood cells for anaemia or other problems.
b. Urine Tests
A simple dipstick test of the urine may confirm that an infection. It is likely that urine will also be sent to the laboratory for culture to confirm any infection and to find out which antibiotics need to be used (culture & sensitivity assessment).
c. Other specific tests
If you have any discharge (from the penis or vagina), swabs may be taken for culture.
Your GP may also arrange an ultrasound scan of your kidneys and bladder. This is not needed for a first infection in a woman but is usually performed for:
- recurrent infections in women (more than 3 attacks per year)
- all infections in men
- infections which have spread to the kidneys
- pregnant women
- diabetics
- patients with known neurological problems
- patients with known abnormalities of the urinary tract
- patients taking drugs which suppress the immune syste
If you fall into any of these groups, your GP will then arrange a formal referral to a urologist for further investigation. This may involve examination of the bladder as well as the investigations mentioned above.
What treatments are available for this problem?
General measures
Mild urinary infections can sometimes be cured by drinking plenty (6-8 glasses) of water daily and relieving any discomfort with simple painkillers (aspirin, paracetamol). It is, however, best to see your GP for advice especially if this is your first urinary infection.
If your symptoms are clearly caused by sexual intercourse (so-called “honeymoon cystitis”), you should refrain from sex until your infection has cleared completely.
If your symptoms worsen despite these measures, you should contact your GP immediately.
Antibiotics
More severe infections usually require treatment with antibiotics. Your GP will normally prescribe an antibiotic (pictured) on a “best guess” policy, taking into account any allergies you may have. The drug given initially may need to be changed. This will depend on the results of laboratory culture and on the sensitivity of any bacteria to the antibiotic already prescribed. Even if no bacteria are grown from your urine sample, there is good evidence that antibiotics can be helpful in curing your symptoms. You will normally be asked to provide a further urine specimen 7-14 days after you have completed your course of antibiotics. This is important to ensure that there is no infection remaining and that any abnormal white cells or red cells in the urine have been eliminated. If they have not, further investigations may be needed to exclude problems such as stones, bladder cancer or tuberculosis.
Surgery
Surgery is rarely indicated for urinary infection unless there is an underlying causative condition which requires surgical relief.
- In patients (especially children) shown to have reflux of infected urine back from the bladder to the kidneys, surgery may be recommended to stop the reflux.
- In some women after the menopause, ultrasound shows poor bladder emptying with a large residual urine and inspection of the bladder with stretching of the neck of the bladder under a brief general anaesthetic may be helpful. Hormone replacement therapy (HRT) using tablets, creams or pessaries may be prescribed after the procedure, to prevent the problem from recurring.
How can I prevent further attacks of infection?
If you suffer from repeated attacks of urinary infection, especially in women, your GP or urologist may recommend that you take low-dose antibiotics for 3-6 months
As an alternative to long-term antibiotics, you may find it helpful to take cranberry juice or tablets. Cranberry preparations have been shown, scientifically, to reduce recurrent infections. Some patients find tablets more palatable than juice. There are also a number of measures you can do for yourself to prevent further infections.
Urinary infection (child)
What causes a urinary infection?
Urinary infection occurs when bacteria enter the the urinary tract via the bladder and multiply to cause an infection. In children, bacteria may move from the bladder to the kidney(s), as a result of ureterovesical reflux.
Is a urinary infection important or serious in children?
- Urinary infections can make children feel very ill with non-specific symptoms such as vomiting, abdominal pain and a high temperature
- Renal scarIf infection enters the kidney(s) by reflux, the infection may cause a scar to form in the kidney(s)
- Scarring of the kidney (pictured) due to infection is permanent. This can cause problems with kidney function and may cause high blood pressure in later life
- Urinary infections in children must be treated without delay to prevent scarring
- Urinary infections may be an indicator of problems (abnormalities) within the urinary tract. These abnormalities may be a risk factor for future problems, including further infections
How will I know if my child has a urinary infection?
Symptoms of urinary infection may vary considerably with age. Infection may occur without the “fishy” smell and burning pain which adults often experience. In babies and young infants, urinary infection often has very non-specific features. If your child has a temperature without any obvious reason (such as a cold or cough), you should try to collect a urine specimen so that infection can be ruled out.
Symptoms in infancy:
- High temperature (fever)
- Tiredness
- Irritability
- Poor feeding
- Smelly nappies
- Vomiting
- Abdominal pain (“tummy ache”)
Symptoms in childhood:
- High temperature (fever)
- Increased frequency of passing urine
- Tiredness
- Vomiting and / or diarrhoea
- Being “off their food”
- Abdominal pain (“tummy ache”)
- Back pain
- Bed wetting (when previously dry)
- Smelly or bloody urine
- Pain when passing urine
How will a urinary infection be confirmed?
A sample of your child’s urine will need to be collected to look for signs of infection & dehydration. How the urine sample is collected will depend on your child’s age and how ill he/she is
The following headings describe the common ways in which urine can be collected from a child:
1. The older child who is toilet trained
a. Mid-stream urine (MSU) collection
- The child’s genitalia are cleaned with warm, soapy water
- The child begins to pass urine into the toilet
- Part way through passing urine, a specimen is collected into a sterile container
- The last part of the urine is then passed into the toilet again
2. The non-toilet trained child
a. “Clean catch collection” (preferred because of the low risk of contamination from skin or bowel motions)
- The child’s genitalia are cleaned with warm, soapy water
- Part way through passing urine, the collection is made in a container held under the child, without touching the child’s skin
b. Urine collection bagUrine collecton bag
- The child’s genitalia are cleaned with warm, soapy water and dried
- A special collection bag is stuck over the child’s urethral opening (“water passage”)
- As soon as urine enters the bag, the bag is promptly removed & the urine transferred into a sterile container
- If the collection is contaminated by bowel motions, the whole process must be started again
3. Very ill children (or those in whom it is difficult to catch a urine sample)
a. Specimen collection from a urinary catheter
- The child’s genitalia are cleaned with saline (salt solution)
- A small catheter is inserted into the bladder, through the urethra, by a doctor or nurse
- A specimen of the drained urine is collected in a sterile container
- The catheter is removed
b. Specimen collection from a suprapubic aspirateSuprapubic aspiration
- The skin in the lower part of the child’s abdomen (“tummy”) is cleaned with an antiseptic solution
- A fine needle is passed through the skin directly into the child’s bladder
- The aspirated urine is placed into a sterile container and the needle is removed
Collecting a urine sample from a child who is not toilet trained can be difficult and frustrating. Whilst using a collection bag may seem simple, this specimen is easily contaminated and the results are not as accurate as midstream or clean catch samples. Your Specialist Nurse, GP or Health Visitor can help you learn more about this.
How will my child’s urine infection be treated?
In babies and infants who are unwell, your doctor will not normally wait for the laboratory results to become available (this can take up to 48 hours) but will start treatment immediately with antibiotics. It may be necessary to change the antibiotic if your child is showing no improvement or if the laboratory results show that a different antibiotic would be better.
To clear the infection, it is very important that your child takes all the antibiotic medicine exactly as prescribed.
In most children, the fact that the child has improved is sufficient to say that the infection has cleared. In a few children (especially those with known abnormalities in the urinary tract), it is important that a further urine sample is collected and sent to the laboratory after the antibiotics have finished. This will confirm that the infection has been completely cleared. In these cases, it is best sent three days after the antibiotic course has been completed. If any traces of infection are found, the infection can come back again.
Will my child need further tests?
In a child over one year of age, additional investigations are not necessary unless the infections keep recurring or the bacteria found are unusual
It is normally recommended that children who have had a urinary infection before their first birthday should have an ultrasound scan of their kidneys, ureters and bladder. This is because a urinary infection can be the first clue to the presence of an underlying physical problem within the urinary tract. If any abnormality on the ultrasound is found, or if the infecting bacteria are unusual in any way, other tests and investigations may be needed
How can my child & I prevent further urinary infections?
- Ensure your child drinks plenty of fluids throughout the day so that he/she actually need to pass urine more frequently and the urine is lighter in colour (more dilute). Drinks should be water or water-based (e.g, squash) rather than tea/coffee/fizzy drinks
- Include a glass of cranberry juice in your child’s diet every day
- Ensure that your child goes to the toilet to empty his/her bladder regularly (e.g. on waking, mid-morning, lunch, mid-afternoon, teatime & before bed)
- Change nappies regularly
- Teach girls to wipe from front to back after passing urine so that germs from the anus do not enter the urethra
- Avoid scented soaps, bubble baths and hair washing with shampoo in the bath
- Encourage your child to wear only cotton underwear
- Ensure your child has a healthy diet
- Bio-yogurt may help by increasing “good bacteria”
- Constipation should be avoided. Ensure that your doctors are aware of any problems with constipation so that it can be treated immediately
- Follow the advice given to you about antibiotic treatment
Your doctors may decide that, to help prevent further infection, your child needs “prophylactic” antibiotics. This is a smaller dose than is used to treat an actual infection. It is intended to prevent infection from becoming established. Prophylactic antibiotics are best taken at bedtime.
Blood in the semen (haematospermia)
What should I do if I have blood in my semen?
If you see blood in your semen, you should contact your GP for further advice although it is unlikely that there is a worrying underlying cause
Your GP will normally provide reassurance about blood in the semen. Most GPs will perform some simple, baseline tests. You may be commenced on antibiotics or anti-inflammatory drugs to treat presumed infection/inflammation. It is not normally necessary for you to be referred for more detailed investigations unless your prostate gland feels abnormal, there is associated blood in the urine or your PSA blood test is abnormal.
What are the facts about blood in the semen?
The commonest cause of blood in the semen is low-grade infection or inflammation in the seminal tract (particularly in the prostate gland)
- Although possible, it is unlikely to be caused by sexually-transmissible infection
- Rarely, it can be due to cancer of the testis or the prostate gland
- If it is associated with blood in the urine, whether visible or non-visible (found on a urine test), it should always be investigated fully
- If it is associated with an abnormal prostate gland on rectal examination or a raised PSA blood test, you will normally be referred to your local urology department on the “fast-track” (2-week wait) system
- Blood in the semen usually resolves spontaneously or with the help of anti-inflammatory drugs
- Recurrence over a long period of time is common
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with blood in the semen. This will normally include some or all of the following:
1. A full history
Your GP will ask you questions about any recent symptoms (especially pelvic pain), any associated matters (including any drugs you are taking) and will enquire about smoking habits. You should inform your GP if you are taking blood-thinning drugs (warfarin, dicoumarin) or if you take anti-platelet treatment (aspirin, dipyridamole, clopidogrel). If the blood in the semen is painful or associated with blood in the urine, it is likely that he/she will arrange referral to a urologist.
2. A physical examination
A general physical examination will be performed, together with a rectal examination and assessment of your testicles. Your blood pressure may be measured as part of this examination.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion but it is common to measure kidney function, clotting factors, prostate-specific antigen (PSA) and to check the blood cells for anaemia or other problems.
b. Urine testing
A urine test will normally be sent for infection. Your GP may commence you on antibiotics whilst awaiting the result of this test. If there is blood in your urine, fresh urine may be sent to the laboratory for microscopic examination, to look for cancerous cells.
Testing the semen for infection is not normally performed because harmless bacteria are often found in semen and are not the cause of any infection.
c. Other specific tests
Your GP may arrange an ultrasound scan of your kidneys and bladder, pictured right. This is more likely to be arranged by the urology department who may also request a rectal ultrasound scan of your prostate gland and seminal vesicles.
What could have caused the blood in my semen?
Most patients with blood in the semen have low-grade prostate, urethral or seminal vesicle inflammation which requires no specific treatment and often resolves spontaneously.
Although there are many potential causes for blood in the semen, it is often difficult to identify a clear cause. Those most often found are:
- Low-grade seminal tract infection (± urinary tract infection)
- Blood disorders (e.g. sickle cell disease, clotting disorders, anticoagulant and anti-platelet drugs)
- Recent urological surgery (e.g. cystoscopy, prostatic biopsy, vasectomy, vasectomy reversal
- Testicular or prostate cancer (very rare)
- Other causes, including less common infections (e,g. TB, schistosomiasis)
What happens next?
It is very unusual for men with blood in the semen to require urological referral
Your GP will reassure you that the condition usually improves by itself. If the blood in the semen persists, your GP will normally prescribe a 6-8 week course of antibiotics or anti-inflammatory drugs. Urological referral may be considered if:
- your prostate feels abnormal on rectal examination and/or your PSA blood test is abnormal
- examination or ultrasound reveals an abnormal testicle
- there is blood in your urine (visible or invisible)
- you have persistent blood in the semen, despite adequate treatment, especially if you are over the age of 45 years
This will involve an outpatient appointment when some or all of the following assessments will be performed:
- Detailed questioning about your urinary tract and any related symptoms
- A physical examination (including rectal & scrotal examination)
- Blood tests (if not already performed by your GP)
- Examination of the urine for cancer cells (if not already performed by your GP)
- X-rays or scans
This may involve one or more of the following:
- CT scan
- ultrasound scan of kidneys & bladder
- rectal ultrasound scan of the prostate
- ultrasound of the scrotum
A flexible cystoscopy (if you have persistent blood in the urine)
this is a telescopic check of the bladder. It is performed under antibiotic cover & local anaesthetic using a small, flexible telescope which allows the clinic doctor to see inside your bladder (pictured). If you have concerns about this or have experienced problems with local anaesthetic in the past, you should ask about having your examination under a brief general anaesthetic (i.e. whilst you are asleep). When your tests have been completed, the medical staff will advise you on what to do next:
If an abnormality requiring further treatment is detected, the medical staff will advise you on what treatment is necessary. If no specific abnormality is found, you should keep a careful eye on your symptoms and report any further bleeding to your GP who will be informed of the result of your assessment.
Blood in the urine (haematuria)
What should I do if I have blood in my urine?
If you see blood in your urine, with or without symptoms of cystitis, you should contact your GP immediately for further advice
Your GP will normally investigate blood in the urine as a matter of urgency. Most GPs will perform some simple, baseline tests. You may be commenced on antibiotics to treat a presumed infection. However, if the urine test result comes back showing no evidence of infection, you will normally be referred to your local urology department for more detailed investigations using the “2-week wait” (fast-track) system.
What are the facts about blood in the urine?
- The commonest cause of blood in the urine in the UK is infection (cystitis)
- Proven blood in the urine, whether visible or non-visible (found on a urine test), should always be investigated
- 1 in 5 adults with visible blood in the urine and 1 in 12 adults with non-visible blood in the urine are subsequently discovered to have bladder cancer
- Children with blood in the urine rarely have cancer – they usually have infection in the bladder or kidney inflammation (nephritis).
- A “one-off” finding of a small trace of blood in the urine on routine testing may not be significant
- Some drugs (e.g. rifampicin, nitrofurantoin) and foodstuffs (e.g. beetroot) can turn the urine red and mimic blood in the urine
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with blood in the urine. This will normally include some or all of the following:
1. A full history
Your GP will ask you questions about any recent symptoms, any associated matters (including any drugs you are taking) and will enquire about smoking habits. Exposure to industrial chemicals or to substances that may be related to bladder cancer development are also important. You should inform your GP if you are taking blood-thinning drugs (warfarin, dicoumarin) or if you take anti-platelet treatment (aspirin, dipyridamole, clopidogrel). If the bleeding is painless and associated with clots of blood in the urine, it is likely that he/she will arrange urgent referral to a urologist.
2. A physical examination
Rectal examinationA general physical examination will be performed, together with a rectal or vaginal examination. Your blood pressure may be measured as part of this examination.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, clotting factors, prostate-specific antigen (PSA) and to check the blood cells for anaemia or other problems.
b. Urine testing
A urine test will normally be sent for infection. Your GP may commence you on antibiotics whilst awaiting the result of this test. Fresh urine may also be sent to the laboratory for microscopic examination and to look for cancerous cells. Your GP may arrange a 24-hour urine collection to measure your urine protein levels.
c. Other specific tests
Your GP may arrange an ultrasound scan of your kidneys and bladder, pictured right (or a CT scan of your abdomen) although this is usually performed in the urology department.
What could have caused the blood in my urine?
50% (half) of patients with visible blood in the urine will have an underlying cause identified but, with non-visible blood in the urine, only 10% will have a cause identified
Although there are many potential causes for blood in the urine, those most often identified are:
- Bladder infection
- Cancers of the bladder (pictured), kidney or prostate
- Stones in the kidneys or bladder
- Inflammation of the kidneys (nephritis)
- Urinary tract injuries
- Blood disorders (e.g. sickle cell disease, clotting disorders, anticoagulant and anti-platelet drugs)
- Other causes, including less common infections (e,g. TB, schistosomiasis)
What happens next?
Assessment of the cause of blood in the urine at hospital (usually in a so-called Haematuria Clinic) may not identify a definite cause but it will, normally, rule out significant causes which require further urological treatment
Your GP may decide that you do not require any further tests at this stage. In this case, you should have regular monitoring to assess the following, which may be signs that re-investigation is needed:
- the development of other urinary symptoms
- further episodes of blood in the urine
- increasing levels of protein in your urine
- progressive deterioration in your kidney function
- the development of hypertension (high blood pressure)
Your GP will arrange urgent referral to the Haematuria Clinic of your local urology unit:
- if you have visible blood in the urine in the absence of infection
- if the blood fails to clear following antibiotic treatment for urinary infection
- if you have non-visible bleeding but significant urinary symptoms
- if you have persistent non-visible bleeding and you are over the age of 40 years
This will involve a prolonged outpatient appointment when some or all of the following assessments will be performed:
- Detailed questioning about your urinary tract and any related symptoms
- A physical examination (including rectal or vaginal examination)
- Blood tests (if not already performed by your GP)
- Examination of the urine for cancer cells (if not already performed by your GP)
- X-rays or scans
This may involve one or more of the following:
- X-rays or scans
This may involve one or more of the following:
- CT scan
- ultrasound scan
- intravenous urogram (IVU)
IVU and CT scanning involve an iodine-based injection. You must inform the staff if you have a history of allergy to iodine or to previous X-ray injections.
A flexible cystoscopy
It is performed under antibiotic cover & local anaesthetic using a small, flexible telescope which allows the clinic doctor to see inside your bladder (pictured). If you have concerns about this or have experienced problems with local anaesthetic in the past, you should ask about having your examination under a brief general anaesthetic (i.e. whilst you are asleep). When your tests have been completed, the medical staff will advise you on what to do next:
If an abnormality requiring further treatment is detected, the medical staff will advise you on what treatment is necessary and what this would involve (e.g. admission for telescopic removal of a bladder tumour).
Telescopic removal of a bladder tumour(video courtesy of Dr Manoj Talwar)
If no specific abnormality is found, you should keep a careful eye on your symptoms and report any further bleeding to your GP who will be informed of the result of your assessment.
Erectile Dysfunction (impotence)
What should I do if I have problems with impotence?
Your GP will normally wish to review both you & your partner together and several visits may be needed before a full picture of the problem can be obtained. Following initial discussions, it is not unusual for some couples to decide not to pursue any further investigations or treatment for impotence (erectile dysfunction).
What are the facts about impotence?
- Impotence becomes commoner with increasing age and is seen in 50-55% of men between 40 and 70 years old
- It is often associated with the so-called “deadly quartet” of obesity, high blood pressure, high cholesterol & diabetes which are all significant risks to health
- Investigation is only indicated if both partners wish to pursue treatment
- Most treatable causes can be identified by a clinical history, physical examination and routine blood tests
- If there is no treatable cause, treatment with tablets is the first option for most men
- Other methods of treatment are only indicated if tablets prove ineffective, cause side-effects or cannot be used because of specific medical conditions
What should I expect when I visit my GP?
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption). He/she will take a detailed sexual history to determine why your erections are failing and under what circumstances you are having sexual difficulties. It is also normal to ask about your sex drive (libido), whether you still get night-time or early-morning erections and whether your partner is also concerned about your difficulties.
It is important to tell your GP if you have premature ejaculation (uncontrolled ejaculation before or immediately after penetration) or symptoms of prostatic obstruction because they are often associated with impotence (erectile dsyfunction).
Your GP may help you to complete a symptom questionnaire (the International Index of Erectile Function) as an aid to further assessment and discussion of treatment options. This will allow your GP to:
- identify your needs & expectations
- help you & your partner share in decision-making
- decide whether psychosexual counselling might be helpful.
2. A physical examination
A general physical examination will be performed to assess the development of your male sexual characteristics and to detect any abnormality of your penis or genitals. Your blood pressure will normally be measured as part of this examination. The pulses in your legs will normally be assessed and the nerve reflexes involving your legs and your penis or anus (back passage). Rectal examination (pictured) is normally performed to assess the tone of your anal muscles and to feel your prostate gland.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function, liver function, cholesterol & prostate-specific antigen (PSA) as well as checking your blood cells for anaemia or other problems. A blood sugar measurement will be performed to exclude diabetes.
b. Routine urine tests
Your urine will normally be assessed by stick-testing to see whether it contains sugar which might indicate diabetes.
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured.
d. Other specific tests
Other tests, if indicated, are normally arranged by the urology clinic. Your GP may be able to arrange measurement of blood flow in your penis by ultrasound, formal nerve conduction tests and even a trial injection of a drug called prostglandin E1 (Caverject®) into your penis. A good erection after the injection means that the arterial blood flow to your penis is likely to be normal.
What could have caused my impotence?
Although a psychological component, often called “performance anxiety”, is common in men with impotence, a purely psychological problem is seen in only 10%.
Of the 90% of men who have an underlying physical cause, the main abnormalities found are:
- Vascular disease in 40%
- Diabetes in 33%
- Hormone problems (e.g. high prolactin or low testosterone levels) & drugs (e.g. antihypertensives, antipsychotics, antidepressants, antihistamines, heroin, cocaine, methadone) in 11%
- Neurological disorders in 10%
- Pelvic surgery or trauma in 3-5%
- Anatomical abnormalities in 1-3% (e.g. tight foreskin, short penile frenulum, Peyronie’s disease, inflammation, penile curvature)
What treatments are available for this problem?
Initial treatment will usually involve:
- treatment of any anatomical abnormality (e.g. circumcision, frenuloplasty, penile straightening)
- treatment of any hormone abnormality (testosterone treatment is only indicated if your testosterone levels are low and may be harmful if your the levels are normal)
- lifestyle modification (e.g. reduce stress, stop smoking & drinking, stop all drugs)
- weight loss & increased exercise (which may reduce the risk of impotence by up to 70%)
- specific support for psychological problems
If these fail to help, your GP will issue a prescription for Viagra®, Cialis® or Levitra®. These drugs require sexual stimulation to be effective and will not produce an erection without it. They will have no effect on your sex drive. There is no evidence that these drugs are dangerous if you have underlying heart disease. However, they should not be taken if you are taking nitrates (e.g. GTN, isosorbide for angina).
You should only take Viagra, Cialis or Levitra by getting a prescription from your GP & you should have a detailed discussion about the risks & benefits before starting treatment.
1. Penile injections to produce erections
Self-administered injections of prostaglandin E1 (Caverject®) provide a simple means of obtaining a natural erection. You will be taught how to administer the injections (pictured) and told what to do in the event of problems such as an erection which will not go down.
2. Medicated urethral system for erection (MUSE)
Insertion of a prostaglandin pellet in the urethra (water pipe) is no longer widely used because of its poor success rates and significant side-effects.
3. Vacuum erection assistance devices (VEDs)
VEDs provide a simple way of obtaining an erection for 30-45 minutes by sucking blood into the penis and holding it in place with a constriction (pictured). Ejaculation may be restricted by the ring but this technique is simple, safe and has no known side-effects. Unfortunately, most patients have to purchase VEDs themselves.
4. Vascular surgery/angioplasty
If you have blockage of the large blood vessels to the legs and the pelvis, it may be possible to undergo reconstruction of the arteries or angioplasty to re-establish erections. Re-vascularisation for small artery blockage is rarely successful.
5. Penile prostheses
Insertion of artificial penile implants (pictured) is highly effective. It is reserved as a last resort when all other forms of treatment have failed. It involves major surgery with a significant risk of complications. You will need to undergo long-term follow-up in a specialist andrology unit for many years after the surgery.
Fertility problems
What should I do if I have fertility problems?
If you have been trying unsuccessfully to produce a pregnancy for 1-2 years, without using any form of contraception, you should contact your GP for further advice.
Your GP will normally wish to review both of you initially. Further investigations may reveal that only one partner has a problem contributing to the infertility. As a general rule, most urologists only deal with problems affecting the male partner. Investigations in the female partner are not considered on this website.
What are the facts about male infertility?infer
- 10% – 15% of couples in Kenya are unable to have a child.
- In 60% of these couples, the problem lies wholly or partly with the male partner
- Urological investigation may reveal a reversible underlying cause for male-factor subfertility and full assessment by a urologist is recommended
- In many cases, no underlying cause is found, in which case assisted conception may offer the best chance of pregnancy
- Infertile couples are often assessed in gynaecology gepartments and, therefore, subfertile men may wish to seek a urology assessment from a urologist specialising in andrology
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men with infertility. This will normally include some or all of the following:
1. A full history
Your GP will enquire about lifestyle factors (e.g. your job, work pressures, smoking habits, alcohol intake and drug consumption) as well as asking whether you have previously fathered children. Your past medical history may also be relevant in identifying a reason for your infertility, especially if you have had previous testicular infections or operations. You will be asked about when you have been having sexual intercourse. Ideally, this should be timed to coincide with your partner’s ovulation (approximately 7-10 days before the next menstrual period).
2. A physical examination
A general physical examination will be performed, paying particular attention to the development of your male sexual characteristics. Your blood pressure will normally be measured as part of this examination.
Special attention is paid to your genitals – shape, size and consistency of your testicles, and the presence or absence of all the structures which attach to the testicles and carry sperms. Your GP will also look for evidence of enlarged, varicose veins (a varicocele) in your scrotum, usually above the left testicle but, very occasionally, on the right.
3. Additional tests
The usual tests performed are:
a. Sperm counts
You will need to provide at least two semen specimens for analysis. Click here for information on how to do these specimens (opens a PDF file in a new browser window). A sperm count of more than 15 million normal, motile (active) sperms per ml should be sufficient to allow pregnancy by natural means
b. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function and to check the blood cells for anaemia or other problems
c. Hormone measurements
Blood levels of testosterone, prolactin, FSH (follicle-stimulating hormone), LH (luteinising hormone) and thyroid hormones will normally be measured. Anti-sperm antibodies are not routinely measured during assessment of male infertility
d. Other specific tests
Other tests, usually performed by specialists, may include chromosomal studies, ultrasound of the scrotum and, possibly, the prostate area.
What could have caused my infertility?
In 75% of infertile men, the cause remains unexplained (this is termed “idiopathic infertility”). It may, however, still be possible for couples to conceive naturally, provided some sperms are present.
Physical abnormalities
Absence or blockage of the tubes that carry sperms (vas deferens) is uncommon but may be treatable. The best-known cause of blockage is, of course, vasectomy which, like scarring due to infection, may be treatable surgically by reconstruction or bypass.
A Varicocele is seen in 20% of infertile men (and in 10% of the normal male population). Surgical treatment has little effect on natural pregnancy rates and is usually reserved for those with symptoms (aching discomfort) or to improve semen quality in couples undergoing assisted conception.
Childhood surgery, especially for undescended testicles or hernias, may be associated with reduced fertility in later life.
Genetic causes
10% of infertile men have an underlying genetic problem. Typically they have very poor sperm counts or no sperms at all. In men with no sperms, hormone measurements help to determine whether this is genetic (primary testicular failure) or associated with obstruction. The former is untreatable whilst the latter can usually be treated successfully.
Other factors
All of the following can have harmful effects on sperms:
- smoking
- excess alcohol consumption
- tight-fitting clothing
- prolonged sitting
- drugs, both prescribed (e.g. steroids) and recreational (e.g. cannabis, cocaine)
What treatments are available for this problem?
Many couples produce a pregnancy whilst undergoing investigations or treatment for infertility (85% within the first year) but, for those who do not, a number of treatments are available
General Measures
If you have poor sperm counts, you should wear loose-fitting trousers and boxer shorts. You should stop smoking, reduce your drug consumption and endeavour to adopt a “healthy” lifestyle. Spraying or splashing the scrotum with cold water 2-3 times a day may also be beneficial.
Drug treatment
Many drugs have been used to improve sperm counts. None has been found to be beneficial although steroids may be useful if you have anti-sperm antibodies after vasectomy reversal.
Surgery
Surgical bypass may be possible for obstruction caused by infection or surgical injury. There is, however, an increasing tendency to avoid surgery in this situation and to use sperm retrieval with assisted conception.
Vasectomy reversal is 75-90% successful in restoring sperm production. Unfortunately, restoration of sperms does not guarantee a pregnancy if your sperm count is low or if your sperms are of poor quality.
Intrauterine insemination (IUI)
Selecting out the most motile sperms and injecting them directly through the cervix at the time of ovulation, whilst employing drug-induced ovarian stimulation in the female partner, results in a 7-8% pregnancy rate for each cycle of treatment.
Intracytoplasmic insemination (ICSI)
In this type of in vitro fertilisation (IVF) a single sperm is injected directly into an egg to fertilise it. It is useful if you have a very low sperm count. It may be necessary to extract useful sperms directly from the testicle or from the epididymis (sperm-carrying mechanism). The procedure carries risks for the female partner and has a pregnancy rate of 20-30% per cycle.
Donor insemination (DI)
Donor semen is carefully screened for infections and a donor selected to have similar attributes to you. This is the only viable option if you have no sperms at all and you do not have obstruction which can be relieved surgically.
Adoption
If you are unfortunate and do not to have any success with other treatments, you may wish to consider adopting a child. Your GP and local / national adoption agencies can help with this process.
Tight foreskin (phimosis)
What should I do if I have a tight foreskin?
If you are unable to retract your foreskin fully, especially if it becomes red or painful, you should contact your GP. If a tight foreskin has been retracted and cannot be brought forward again, you should seek urgent treatment in your local hospital
In adults, tightness of the foreskin may cause no symptoms for most of the time. Problems usually become more obvious (and troublesome) when you get an erection and attempt sexual intercourse.
- In most children, the foreskin cannot normally be retracted completely before the age of 5. In some, full separation may not take place until the age of 10.
- Injury or infection of the foreskin may contribute to tightening.
- Foreskin ballooningBallooning of the foreskin (blowing up when passing urine) does occur with a tight foreskin but may also occur in children with a normal foreskin.
- Tightness of the foreskin may interfere with the normal passage of urine and can, in severe cases, cause acute retention of urine.
- Tight foreskins may encourage tumours of the penis to develop but tumours never arise in patients who have been circumcised in childhood.
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for men or boys with a tight foreskin. This assessment will normally include some or all of the following:
1. A full history
Your GP will take a full history including whether you have had any injuries or infections of the penis at any stage. He/she will also assess the effect that the tight foreskin is having on your sexual activity.
2. A physical examination
A general physical examination will be performed which will include examination of your penis and foreskin. In some patients, the problems you are experiencing may be caused by a short penile frenulum rather than by genuine tightness of the foreskin.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to the discretion of your GP. It is important to exclude diabetes with a blood glucose measurement. No other specific investigations are normally necessary.
b. Urine tests
Your urine will normally be tested to exclude infection and will be specifically tested for the presence of glucose (sugar).
c. Other specific tests
Your GP may take swabs from the foreskin area to send to the laboratory for bacterial culture.
What could have caused my tight foreskin?
In children, a tight foreskin is usually congenital but, in adults, it is often due to a scarring disease known as balanitis xerotica obliterans (BXO, sometimes called lichen sclerosus). We do not know the cause of BXO
What treatments are available for this problem?
If simple conservative measures fail to improve the tightness, your GP will normally recommend referral to a urologist for further advice
General measures
- Stretching of the foreskin is best avoided. There is no scientific evidence that it produces a cure and it can actually precipitate tearing and scarring. This may worsen a phimosis which then requires surgical treatment later in life. Forcible retraction of the foreskin in children should be avoided.
- Steroid creams may soften your foreskin if the scarring is mild; stopping the cream, however, may result in a return of the condition.
- Antibiotics may be needed if swabs show any evidence of infection
- Using a condom during sexual intercourse may make the penis more comfortable
Surgery
Circumcision is the mainstay of treatment if the foreskin is scarred by balanitis xerotica obliterans. This is one of medicine’s oldest operations.
Prepuceplasty is effective In children with congenital tightening of the foreskin. Several incisions are made into the tip of the foreskin to expose the head of the penis. The foreskin then needs to be retracted regularly until it has healed completely.
This procedure is totally ineffective in adults
Frenuloplasty is the best option If the tightness is due to a short penile frenulum, rather than a tight foreskin. However, a short frenulum may also be associated with a some scarring of the foreskin, so full circumcision is needed in some patients.
Partial removal of the foreskin is not recommended. Scarring may return in the foreskin remnant and the cosmetic results, particularly during erection, are often unacceptable.
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Testicular lump
What should I do if I have a testicular lump?
If you find a lump inside the scrotum, not arising from the skin of the scrotum itself, you should contact your GP immediately for further advice. To feel for testicular lumps, it is best to examine yourself when you are warm and relaxed (e.g. after a bath or shower). Stand in front of a mirror and hold each testicle in turn between your fingers. Feel the body of the testicle and all the structures attached to it.
testicular lump
If your GP is concerned that you could have testicular cancer, you may be referred urgently to the urology department using the fast-track (2-week wait) referral system.
What are the facts about testicular lumps?
- The vast majority of swellings in the scrotum are benign and should not give cause for concern
- Benign swellings in the scrotum only require surgical treatment if they cause significant symptoms (e.g. aching, cosmetic embarrassment)
- A simple ultrasound scan will usually differentiate between benign and cancerous swellings
- If the lump is attached to the surface of the testicle, it is probably benign
- If a lump is within the body of the testis itself, there is a 90% chance that it is a testicular cancer
- Testicular cancer is the commonest malignant tumour in men between 20 and 50 years old
- Whilst testicular cancer is rare in men over the age of 50, certain forms do occur and you should always seek advice from your GP
- Testicular cancer is commoner in abnormal testicles e.g. previously undescended testicles, testicles which have been injured or infected and soft, atrophic testicles (sometimes seen in infertile men)
- Early diagnosis and treatment mean that more than 95% of men can be cured of testicular cancer, even if it has spread beyond the testicle itself
What should I expect when I visit my GP?
Your GP should work through a recommended scheme of assessment for patients with a scrotal swelling. This will normally include some or all of the following:
1. A full history
Your GP will take a full history, paying particular attention to any possible trauma or infection of the testicles in the past. You should mention any previous operations on your testicles to your GP, especially surgery for an undescended testicle. Please tell your GP if you have had a vasectomy in the past.
2. A physical examination
A full physical examination will be performed, including examination of your scrotum, your abdomen and your lymph glands. Your blood pressure will normally be measured as part of this examination.
3. Additional tests
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is common to measure kidney function & liver function, and to check the blood cells for anaemia or other problems.
b. Tumour markers
If your GP suspects testicular cancer, he/she may arrange some specific blood tests to measure tumour markers (alpha-fetoprotein, beta-human chorionic gonadotrophin, lactate dehydrogenase).
c. Other specific tests
An ultrasound scan (pictured, showing a testicular tumour) will normally be arranged to assess exactly where the swelling is in relation to your testicle. Depending on the findings of the ultrasound scan, a CT scan of your abdomen & chest may also be arranged. This is normally fixed through the urology unit.
What could have caused my testicular lump?
Swellings of the scrotum are usually cystic (fluid-filled), inflammatory or solid. Clinical examination and ultrasound scanning can usually differentiate between the possible causes.
Cystic (fluid-filled) swellings
These are the commonest swellings and are usually caused by a hydrocele (fluid around the testicle, pictured), a cyst in the epididymis (sperm-carrying mechanism) or varicose veins above the testicle (a varicocele). They are all benign and only require treatment if they cause significant symptoms.
Inflammatory swellings
Infection of the epididymis (sexually-acquired or secondary to a urinary infection), twisting of the testicle (torsion, usually in children) or infection of the testicle itself (e.g. due to mumps) are the commonest causes of inflammation.
Solid swellings
Solid swellings include tuberculosis & syphilis (both very rare nowadays), a sperm granuloma or nodule (usually following a previous vasectomy), chronic inflammation of the epididymis. If the lump is within the testicle itself, it may be a testicular tumour.
Hernias
A hernia arising in the groin can extend down towards the testicle but simple examination will reveal that the swelling does not arise from the scrotum itself. Urologists do not treat hernias and your GP may recommend referral to a hernia surgeon.
What treatments are available for this problem?
Cystic (fluid-filled) swellings
Hydrocele repair, excision of an epididymal cyst (pictured) and open surgery, laparoscopic surgery or radiological embolisation may be needed for significant symptoms from the swelling. Otherwise, no treatment is necessary.
Inflammatory swellings
Antibiotics are used for infection of the epididymis. Your GP may refer you to a urologist (if you are over 50 or have a urinary infection) or to a genitomedical clinic (if you are young or your infection may be sexually-acquired). Testicular involvement with mumps usually requires no specific treatment apart from painkillers. Suspected torsion of the testis requires emergency admission and immediate surgery.
Testicular cancer
If you are found to have testicular cancer, you will be referred urgently to the urology clinic. Following further investigations (see above), you will normally be advised to have the testicle removed as soon as possible. An artificial testicle can be inserted at the same time or at a later date. The need for further treatment (radiotherapy or chemotherapy) is determined by the pathology results, the results of your tumour marker blood tests & the findings on a CT scan. Once surgery has been arranged, you will referred to an oncologist for any further treatment and for long-term follow-up.
Other solid swellings
Tuberculosis and syphilis are rarely seen nowadays but are treated with appropriate antibiotics. Sperm granulomas in the epididymis may be removed if they are uncomfortable but they rarely require treatment.
Testicle missing
What should I do if I have a testicle missing?
If you or your child have a testicle which is not in the normal (scrotal) position, you should contact your GP for further advice.
Your GP may be able to find the missing testicle by simple examination. He/she will also be able to advise you on whether the rest of your genitourinary tract requires investigation.
The commonest reason for a testicle which cannot be seen or felt is that it is retractile. This is especially common in children and is not of any concern. Your GP may be able to demonstrate retraction. This usually means that no immediate treatment is needed, provided the testicle can be brought to the bottom of the scrotum. Retractile testicles usually become less so with time and spend progressively more time in the scrotum with less time in the groin.
What are the facts about a missing testicle?
- The commonest cause of a missing testicle is that it is retractile and not actually undescended
- An undescended testicle is seen in 4% of boys at birth
- Spontaneous descent occurs in 75% of these boys over the first 3 – 6 months leaving 1% of all boys with an undescended testicle after this time
- There are several significant risks when a testicle is misplaced (see below)
- There is an association with other abnormalities of the urinary tract (kidneys, ureters, bladder & urethra)
- Surgical re-location of the testicle (orchidopexy) is needed in most children with an undescended testicle and is best performed before the child’s first birthday
- In adults, removal of the misplaced testicle (with insertion of an artificial testicle, if requested) is usually the treatment of choice
What should I expect when I visit my GP?
Assessment for patients with a missing testicle usually involves a simple examination only but may include some or all of the following:
1. A full history
Your GP will take a full medical history. He/she will should enquire about the use of drugs during pregnancy, whether the testicle was present when the scrotum was assessed after birth, any previous surgical history and whether there is any family history of undescended testis or any other syndromes.
2. A physical examination
A full physical examination will be performed, including examination of the scrotum. This is best performed in comfortable, warm surroundings. It may then be possible to identify a retractile testicle or feel the maldescended testicle in an abnormal site.
3. Additional tests
a. General blood tests
Your GP will decide whether any blood tests are necessary but, in most patients, they are not.
b. Other specific tests
A routine urine stick test will normally be performed. Your GP may arrange an ultrasound, CT scan, MRI scan or a hormone (HCG) stimulation test. These tests, however, are normally requested only by the urology or paediatric department after hospital assessment.
What could have caused my missing testicle?
The causes of undescended testicle are complex and poorly-understood but there is an association with other congenital abnormalities of the urinary tract.
The testicle develops inside the abdomen, just below the developing kidney. It normally descends into the scrotum by the 32nd week of pregnancy. This is a complex process governed by hormones (male & female), the pressure inside the abdomen and a structure known as the gubernaculum (which acts as a tissue wedge to stretch up the passage between the groin and the scrotum). Defects in all these mechanisms contribute in varying amounts to incomplete descent of the testicle.
What treatments are available for this problem?
4% of children have an undescended testicle at birth but 75% of these testicles descend by the age of 3 months. By the age of 1 year, an undescended testicle is unlikely to come down by itself.
The risks of an undescended testicle are:
- reduced fertility in later life (especially if both testicles are affected). Testicles produce sperm (pictured) ideally at a temperature 1-2ºC below body temperature. This temperature is achieved when the testicle is in the scrotum but sperm production is impaired when the testicle lies in the groin (i.e. at normal body temperature)
- increased risk of testicular cancer (up to 40-times increased risk in later life)
- an associated hernia (found in 90% of boys with an undescended testicle)
- twisting of the misplaced testicle which blocks its blood supply and causes it to die
- an increased liability to injury in the groin. Testicles situated normally in the scrotum are mobile and less prone to injury by external forces
- psychological and cosmetic embarrassment in children or young adults
For these reasons, early treatment is normally recommended, as below.
Hormone treatment
Using hormones to stimulate testicular descent in children works best with low-lying testicles. The success rate is less than 20%, so surgery remains the “gold standard” for treatment. Your paediatric urologist will advise you hormone treatment is appropriate for your son.
Hormone treatment is ineffective in adults with an undescended testicle.
Orchidopexy
Orchidopexy is the procedure of choice in children and is best performed during the first year of life. Bringing the testicle into a normal position reduces the risk of testicular cancer developing later in life. However, it probably does not reduce this risk to zero. The procedure involves freeing of the testicle in the groin, repairing the associated hernia and positioning the testicle securely in a pouch in the scrotum.
High-lying testicles, especially those within the abdomen, may require a more complex procedure. It may not always be possible to bring these testicles into the scrotum and, in some children, removal of the testicle will be needed. If it is suspected that the testicle is lying within the abdomen, a preliminary laparoscopy (keyhole inspection of the abdominal cavity) may help to confirm its exact postion. Laparoscopy (pictured right) will also confirm whether the testicle has not formed at all (seen in 5% of children with a missing testicle).
Removal of the misplaced testicle
In adults (beyond the age of puberty), removal of the testicle is normally advised. Even if the testicle is brought down, it is unlikely to have any capacity to produce sperms and there is still a risk of testicular cancer later in life. Insertion of an artificial testicle (pictured) can be performed as part of this procedure.
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